Provider Demographics
NPI:1609580356
Name:DAVIS, MADISSEN KAILYN (ATC)
Entity Type:Individual
Prefix:
First Name:MADISSEN
Middle Name:KAILYN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 9TH ST APT 202
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-4020
Mailing Address - Country:US
Mailing Address - Phone:682-367-3823
Mailing Address - Fax:
Practice Address - Street 1:2210 9TH ST APT 202
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-4020
Practice Address - Country:US
Practice Address - Phone:682-367-3823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960053812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer